Learning with, about, and from COVID-19: An interprofessional global comparison of pandemic responses.

BACKGROUND AND PURPOSE: University of Kentucky developed a fully virtual course to educate global health learners about the COVID-19 pandemic and compare country responses to it. EDUCATIONAL ACTIVITY AND SETTING: Forty-three students participated in 13 weeks of synchronous interprofessional group meetings via Zoom (Zoom Video Communications, Inc) and asynchronous modules. Interprofessionality was intentional yet implicit, and a flipped classroom was utilized. Assessment was accomplished with one instrument measuring learning outcomes associated with select Consortium of Universities of Global Health Interprofessional Global Health Competencies, Association of American Colleges and Universities Global Learning Value Rubric competencies, and course satisfaction and effectiveness utilizing a retrospective pre-/post-methodology. FINDINGS: Positive pre-/post-change was observed in 10 survey items. Evaluation results concerning course structure and experience were uniformly high, with the key informant interview rated most helpful. Items with significant improvement included a better understanding of the student's place in the world; improved interprofessional communication skills; population health data skills; and understanding of health systems and entities that influence global health and development. Learners appreciated the value of interprofessional teamwork and gained a deeper understanding of the roles and training of colleagues from other programs, leading to a deeper understanding of the actions those professions may take within health systems. SUMMARY: The pivot to all online global health education was a viable solution to addressing the pause in global travel and study abroad experiences at University of Kentucky.

The provision of the baby box was associated with safe sleep practices in a low-resource community: a randomized control trial in Ecuador.

BACKGROUND: Sudden Unexpected Infant Deaths (SUID) can occur between 1 month and 1 year of age and are inequitably distributed with a greater burden in populations with numerous health disparities. Modifying the infant sleep environment to promote safe sleep is the most effective risk reduction strategy to reduce SUID. The provision of baby boxes with a mattress and infant supplies has been part of a larger anti-poverty social justice maternity package for decades in Finland. While infant mortality rates have generally improved after the maternity package was introduced, little is known about whether the provision of the baby box increased safe sleep practices. The purpose of the study was to evaluate whether the provision of a Finnish-style baby box reinforced safe infant sleep practice in the home in a low-resource community in Ecuador. METHODS: In this longitudinal randomized controlled trial all participants received the same safe sleep education in their third trimester of pregnancy (n = 100). This was followed by randomization into two groups; the control received a diaper bag and newborn gifts, and the intervention group received a baby box and the same gifts at each timepoint. Four infant sleep practices (room sharing, bed sharing/co-sleeping, position, and soft items in the sleep environment) were assessed at 1 month and 1 months post-delivery during a home visit where safe sleep education was also reinforced with both groups. RESULTS: Those in the baby box group were 2.5 times more likely to report safe sleep practices compared with mothers in the diaper bag group at 1 month (odds ratio [OR] = 2.45 and 95% confidence interval [CI]: 1.03-5.86; χ2 = 4.1, p = .043). The group difference was also present at 6-months post-birth: those in the baby box group were 2.9 times more likely to report safe sleep practices compared with those in the diaper bag group (OR = 2.86 and 95% CI: 1.16-7.05; χ2 = 5.2, p = .022). CONCLUSIONS: While not all participants used the box regularly, the mothers who received the box were more likely to practice safe sleep at 1 month and 6 months. This suggests the baby box may have served as an important prompt towards safer infant sleep practice. TRIAL REGISTRATION: (Clinical Trial Registry, per clinicaltrials.gov : not applicable under 42 CFR 11.22(b) as the study Facility Location was not in the United States (took place in Ecuador), does not involve FDA IND or IDE, and does not involve a drug, biological or device product that is manufactured in and exported from the US for study in another country. The University of San Francisco Quito, Research Ethics Committee in Human Beings approved the study, #2017- 127 M. The University of Kentucky Office of Research Integrity also approved the study, IRB # 42965).

Unintended pregnancy and childhood maltreatment: The protective effect of positive relationships.

BACKGROUND: Childhood maltreatment is associated with sexual risk-taking behaviors in adulthood but can also have generational effects on maternal/child health. METHODS: This cross-sectional study examined the relationship between childhood abuse and neglect and unintended pregnancy, and then assessed the effect of relationship attributes on this outcome. RESULTS: Findings indicate parenting women (n = 153) in long-term relationships who experienced childhood emotional abuse had higher scores of unintended pregnancies (p = .023). Yet women with moderate/high partner appraisal (perceptions of their partner's attributes used to assess interpersonal conflicts) showed no difference in unintended pregnancies between those with and without emotional abuse in childhood. Women with emotional abuse and low partner appraisal had higher unintended pregnancy scores (p = .002). DISCUSSION/CONCLUSION: This study has implications for public health nursing and life course research demonstrating that a positive adult interpersonal environment can reduce the sequelae of adverse health outcomes associated with childhood emotional abuse. The results reinforce the importance of screening adults for childhood maltreatment to establish early risk for unintended pregnancy.

Partnering with recovery community centers to build recovery capital by improving access to reproductive health.

BACKGROUND: People with substance use disorders (SUD), especially opioid use disorder (OUD) have the highest rates of unintended pregnancies (80-95%) and report unmet reproductive health needs. Women of childbearing age have some of the highest death rates from opioids and are notably rising the most rapidly, and when pregnancy does occur overdose is one of the leading causes of maternal mortality. There are numerous gender-based health disparities and social determinants of health shaped by the distribution of power and privilege that influence the risk trajectories of people who can get pregnant or are pregnant with a substance use disorder (SUD). PURPOSE: The purpose of this paper is to describe how reproductive health is essential to recovery and building recovery capital for people who can get pregnant, (1) introduce a pilot implementation science study working with trained peer support coaches to promote reproductive autonomy in the community, and (2) make policy and advocacy recommendations relevant to the new reproductive health landscape in the United States. We will also describe the adaptation and feasibility of the initial pilot study where we partnered with a recovery community center to train peer recovery coaches to provide low barrier resources (contraception, pregnancy tests and prenatal vitamins) and referrals to health care. METHODS: This initiative is the merging of best practices in recovery and community-based global reproductive health, to empower people with SUD who can get pregnant in an implementation science framework. The pilot study will last 3 months in each city and aims to (1) assess and describe the effectiveness of the training of local peer recovery coaches on the link between recovery capital and reproductive health, and (2) assess the feasibility, acceptability, appropriateness, scalability, sustainability, and uptake and reach of low barrier reproductive health resources (pregnancy tests, prenatal vitamins, and emergency contraception). In this paper we are only reporting the initial findings regarding adaptation and feasibility. FINDINGS: Informed by qualitative interviews with stakeholders and participants, the method of contraception was adapted from injectable to emergency to meet the needs and context of the community with SUD. Early outcomes such as uptake and acceptability indicate that this is a feasible model with peer recovery coaches and recovery community centers, with the greatest uptake of emergency contraception and pregnancy tests. CONCLUSION: Considering recent policies limiting access to reproductive health, innovative community-based solutions are needed to engage and empower people who can get pregnant or are pregnant while in active drug use and in recovery. Providing low barrier reproductive health items by people with lived experience with SUD can serve as a valuable harm reduction model and improve recovery capital. CLINICAL RELEVANCE: This is the first study to propose a methodology and context to implement a community-based study merging best practices in recovery with those in reproductive health with the potential to improve recovery capital and maternal/child health trajectories for people with SUD.

Poverty and Paternal Education Associated With Infant Safe Sleep Intentions in a Peri-Urban Community in Ecuador.

Ecuador's annual mortality rate from SIDS is 0.4 per 100 000 people, 4 times higher than neighboring countries Peru, Bolivia, and Brazil. Modifying the infant sleep environment toward safe practice has been demonstrated to be the most effective risk reduction strategy in reducing mortality from SIDS and little is known about sleep practices in Ecuador. The purpose of this study is to describe baseline infant sleep intentions of pregnant women in a peri-urban, low resource community in Ecuador. We also aim to identify demographic and psychosocial factors associated with suboptimal sleep practices in this context to develop long-term strategies to identify infants with high risk for SIDS/SUID. A cross-sectional study design was employed with 100 women in their third trimester of pregnancy. The majority of women were partnered (82%), both parents had approximately 8 years of education, and over half reported that their incomes met or exceeded their basic needs (55%). Significant predictors of safer sleep intention included years of paternal education (P = .019) and income meeting their basic needs (P = .0049). For each additional year of paternal education, families were 23% more likely to report safer intended infant sleep practices. Compared to those whose income did not allow for basic needs, those who had sufficient income to meet (or exceed) basic needs were 425% more likely to report safer intended sleep practices. Targeted interventions to high-risk populations may reduce the burden of SIDS/SUID in this community.

Social support reduces the risk of unintended pregnancy in a low-income population.

Almost half of all pregnancies (45%) in the United States (US) are unintended, with the highest concentration in women with low incomes. Targeted research is warranted to identify risk and protective factors that influence pregnancy intention to improve maternal/child health. PURPOSE: To identify individual and interpersonal level associations to pregnancy intention to use as leverage points to build resilience. METHOD: A cross-sectional, secondary analysis of Medicaid eligible pregnant women in Kentucky (n = 309). RESULTS: Sixty-two percent reported their current pregnancy was unintended. Older age, partnered, negative drug screen, and increased social support were associated with decreased odds of unintended pregnancy. For every 1 unit increase of belonging and tangible social support, women were 13% and 14% (respectively) less likely to have an unintended pregnancy (OR = 0.87, 95% CI = 0.78-0.97, p = .011, OR = 0.86, 95% CI = 0.77-0.95, p = .005). A positive drug screen was associated with an almost three-fold increase in the odds of unintended pregnancy (OR = 2.88, 95% CI = 1.49-5.58, p = .002). CONCLUSION: Public health nurses can play a critical role in reducing unintended pregnancy rates by promoting social support, inclusion, and acceptance. There remains a critical need to identify barriers and facilitators to pregnancy planning for persons who use illicit drugs.

Using Photovoice to Encourage Reflection in Health Professions Students Completing a Short-term Experience in Global Health.

Objective. To engage health professions students in a photo and caption sharing methodology to stimulate reflection and inculcate principles related to global health at a formative time in training. Methods. Undergraduate and graduate students from multiple colleges enrolled in a course that would prepare them for an in-country global health experience. As part of the course, participants took photos to illustrate one of three topics: global health ethics, interprofessional practice, or social determinants of health. The iterative and participatory photovoice process was used for students to analyze, discuss, and reflect on their work in country and upon return. Final photos with captions were displayed online. Researchers analyzed photos and captions using content analysis to identify unifying themes. All students were required to complete the photovoice assignment, but only those who gave informed consent were included in the qualitative analysis. Results. Twenty-six students were included in the analysis. Two overarching themes emerged: revelation and adaptation. Revelation encompassed novel elements that surprised the students, including differences and similarities between the United States and Ecuador. Coded segments related to adaptation discussed participants' resourcefulness while challenging work environments, and how they would apply this new perspective to their future practice in the United States. Conclusion. This global health photovoice project provided a unique medium for reflection for health care trainees. This project enhanced our understanding of the learners' perspectives and this new means of expression offered the learners a greater opportunity for deeper reflection. The assignment also revealed gaps in learning related to social determinants of health and areas of concern related to solidarity and privilege.

"We keep quiet": exploring the context of pregnancy intention in a low-resource community in Ecuador.

Unintended pregnancies are both a consequence and a cause of socioeconomic inequality. Family planning prevents unintended pregnancy and reduces health disparities. The purpose of this study is to describe the structural, social, economic context of pregnancy intention in a peri-urban, diverse, low-resource community in Ecuador. A qualitative descriptive methodology was used. Semi-structured individual interviews were performed with 19 female participants of reproductive age. Interviews were professionally transcribed in Spanish, translated into English, and analysed in MAXQDA using content analysis. The majority of pregnancies were reported as unintended and four themes emerged to describe the context. (1) Women's autonomy is limited by men, (2) Women keep quiet, (3) Systems failed women, and (4) Building resilience. Health systems, gender-based violence, limited education and financial means, and policies yet to be enforced served as barriers to both empowerment and family planning. In spite of this, many women were able to transition into safety, and prevent or delay pregnancy with new partners. Ecuador has made significant economic gains in the past two decades, but these findings suggest that inequality persists in some regions of Ecuador. The women in this study report needing to feel safe, productive and valued to plan their families. Public health professionals need to involve multi-sectors in solutions to reduce health disparities and address determinants of maternal/child health including gender-based violence, economic and systemic limitations. DOI:10.1080/26410397.2019.1686198.

A pilot interprofessional program to promote oral health and wellness in Appalachian children.

In a first of its kind authentic clinical interprofessional education (IPE) experience, University of Kentucky (UK) health profession students joined dental students to implement a pilot program to promote oral health and wellness with children living in underserved Appalachian communities. Known as hCATS (Health Colleges Advancing Team Skills) to Appalachia, a total of 113 students participated in interprofessional teams of 48 health profession students paired with 65 dentistry students to provide health services. Although the UK College of Dentistry has provided sealant services (tooth decay prevention) to elementary school children for several decades in eastern Kentucky counties, funding through the UK Women and Philanthropy Network allowed services to expand to include general health screening and age-appropriate education on oral health, nutrition, exercise, and prevention of substance abuse. The UK Center for Interprofessional Health Education (CIHE) coordinated the efforts for students from the colleges of Communication and Information Sciences, Health Sciences, Nursing, Pharmacy, Public Health, and Social Work. In addition to the clinical experience in the elementary schools, nursing and other health profession students explored the health resources of the communities visited and reflected on their experience in collaborative practice that the program was designed to encourage. The authors noted positive outcomes with interprofessional education competencies, although more structure for collaboration is required to ensure students who work with other professions in an authentic clinical setting can gain early relevant practice in, and experience the benefits of, collaborative patient care.